1. C ULTURAL C OMPETENCY IN A DOLESCENT M EDICINE : D OES IT MATTER ? David Breland MD MPH Assistant Professor of Pediatrics Division of Adolescent Medicine Seattle Children’s Hospital

2. O BJECTIVES Historical prospective Cultural competency/effectiveness Definitions Value Conceptual frameworks Why important in Adolescent Medicine/Health Suggestions on how to approach cultural effectiveness in adolescence Discussion Videos

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4. H ISTORICAL CONTEXT IS IMPORTANT In the past….. Separate and unequal administration of health care Negative acknowledgement of different races Bias of researchers and clinicians unchecked African American nurses and doctors not allowed to join medical societies Now…. Culture of medicine still seen as key to transmission of stigma, racial bias and the development of health disparities across minority groups Inequity of health care

5. H EALTH E QUITY The absence of systematic disparities in health AND in the major social determinants of health BETWEEN social groups who have different levels of underlying social advantage/disadvantage

6. S EARCH FOR H EALTH E QUITY Recognized need for health equity Medical errors not explained fully by socioeconomics Focus on increasing diversity in workforce Need for diversity in research Cultural competence

7. W HAT IS CULTURE ? Anthropologist Not a single variable but comprises multiple variables affecting all experiences Inseparable from economic, political, religious, psychological and biological conditions Ordinary activities/conditions take on emotional tone and moral meaning for participants Often differ within the same ethnic or social group because of differences in age cohort, gender, political association, class, religion, ethnicity and even personality

8. C ULTURALLY C OMPETENT C ARE “Ability of health care providers and institutions to deliver effective services to racially, ethnically and culturally diverse populations”

9. W HY C ULTURAL C OMPETENCY ? Cultural competency/effectiveness Fashionable term! No one can define the term to operationalize Clear that it does matter in clinical settings Cultural factors crucial to Diagnosis Treatment Ongoing care Shapes health-related beliefs, behaviors and values

10. C ULTURALLY E FFECTIVE C ARE AAP “the delivery of care within the context of appropriate physician knowledge, understand, and appreciation of all cultural distinctions leading optimal health outcomes” AMA Advises clinicians to assess ethnic identity and acculturation of minority and immigrant youth in clinical practice Delivering Culturally Effective Health Care to Adolescents by Fleming and Towey 2001 Key is to recognize there are differences

11. P ROBLEMS WITH THE IDEA OF CULTURAL COMPETENCY Suggest that culture can be reduced to a technical skill for which clinicians can be trained and develop expertise Problem stems from medical definition of culture Often synonymous with ethnicity, nationality and language Cultural factors not always central to a case May hinder a more practical understanding of the case Historically Culture in health care solely domain of patient and family Can also talk about culture of health care

12. W HAT IS THE VALUE ? Large claims of value for cultural competence not supported by robust evaluation research showing improvement in clinical services Might be a failure of outcomes research to take it seriously to evaluate its cost effectiveness Consumer Assessment of Healthcare Providers and Systems (CAHPS) Standardized survey instruments used to collect reliable information from patients about the care they received Assess racial/ethnic and language differences in patient experiences with care CAHPS Cultural Competence (CC)

13. Weech-Maldonado et al, Medical Care, Vol 50, 9(2): 2012

14. R EVISED C ULTURAL F ORMULATION ( BASED FROM DSM IV) Step 1: Ethnic/cultural Identity Ask about ethnic/cultural identity and see if matters Acknowledge and affirm a person’s experience with illness Don’t assume knowledge Step 2: What is at stake? What is at stake as patient and family face illness Shed light on the moral lives of patients and families Step 3: The illness narrative Reconstruct the patient’s illness narrative to acquire understand of the meaning of illness Explanatory model

15. R EVISED C ULTURAL F ORMULATION CONTINUED Step 4: Psychosocial stresses Consider ongoing stresses and social support that make up people’s lives (i.e. family tension) Step 5: Influences of culture on clinical relationships Clinician critical self reflection Unpack the formative effects that the culture of biomedicine and institutions has on the most routine clinical practices Step 6: The problem of a cultural competency approach Efficacy!! Does this intervention actually work in a all cases?

16. G ROWING D IVERSITY OF THE A DOLESCENT P OPULATION Most adolescent minority populations are growing faster than the white populations By 2040 the projected % of non-Hispanic whites in the adolescent population will drop below 50% Hispanics are becoming the second most populous ethnic group Asian/Pacific Islander, though small in number, are growing at the fastest rate The American Indian/Alaska Native population is projected to remain largely unchanged Source: National Adolescent Health Information Center. 2000

17. O THER KEY FACTORS TO CONSIDER IN A DOLESCENCE SES Educational attainment Population characteristic and access to health care Family structure and dynamics Culture of Western medicine Culture’s influence on health care Health beliefs and practices

18. A SSESSING CULTURAL FACTORS WITHIN A H EALTH H ISTORY Integrating adolescent patients’ cultural backgrounds in health assessments can help facilitate communication Asking about significance of their behavior w/in the context of their cultural background Avoid assessment based on dominant culture norms Critical factors SES, educational attainment, family structure and dynamics, cultural beliefs and practices, ethnic origin/identification and language preference

19. U NDERSTANDING ADOLESCENTS ’ PERSPECTIVES ON THEIR HEALTH PROBLEMS 1. How would you describe the problem that brought you to me? 2. What name do you give your problem/illness? 3. Why do you think this problem has happened to you? 4. What do you think will help treat your health problem? 5. Are there things that make you feel better that doctors do not know about? 6. What do you fear most about your illness? 7. Apart from me, who else do you think can help you get better? 8. Has anyone else helped you with this problem? 9. What are the chief problems your illness has caused you or your family?

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23. R EFERENCES Kleinman A, Benson P, Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix it. PLoS Medicine,3(10) 2006: 1673-76. Vo DX, Park MJ, Racial/Ethnic Disparities and Culturally Competent Health Care Among Youth and Young Men. Am Journal of Men’s Health, 2(2) 2008: 192-205. Weech-Maldonado R, Carle A, et al, The Consumer Assessment of Healthcare Providers and Systems (CAHPS) Cultural Competence (CC) Item Set. Medical Care, 50(9) suppl 2, 2012: S22-S31 Fleming M, Towey K, Delivering Culturally Effective Health Care to Adolescents. American Medical Association, 2001.

24. Q UESTIONS ?

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